A 28-year-old female presented to the emergency room with epigastric pain, nausea, and vomiting; her lipase was elevated, and computed tomography of abdomen showed evidence of acute pancreatitis. Her past medical history was significant for poorly controlled insulin requiring type 2 diabetes mellitus and 2 previous admissions for hypertriglyceridemia-induced pancreatitis. Due to the severity of her pancreatitis presentation, she was admitted to the intensive care unit. She received aggressive intravenous fluid hydration and was started on an insulin drip. Apheresis was strongly considered given the degree of her hypertriglyceridemia (11 602 mg/dL), but there was no timely access to this treatment option. She, however, significantly improved with insulin therapy alone. Her triglyceride levels decreased rather quickly to 4783 mg/dL within 24 hours and by the fourth day of admission were comfortably <1000 mg/dL with insulin infusion along with clinical improvement. She was discharged on niacin and insulin therapy along with her home medications of statin and fenofibrate.

Chronic myelomonocytic leukemia (CMML) is a rare clonal stem cell disorder associated with clinical and pathologic of myelodysplasia and myeloproliferation. Systemic autoimmune/inflammatory disorders (SAID) and polyserositis have been associated with CMML. These manifestations can be observed concomitantly, shortly before diagnosis or anytime along the course of illness. We report a case of myeloproliferative CMML who presented with polyserositis and positive serology for rheumatoid arthritis. Retrospective studies of myelodysplasia/CMML have reported 15% to 25% incidence of SAID. The most commonly observed disorders include systemic vasculitis, connective tissue diseases, polychondritis, seronegative arthritis, and immune thrombocytopenia. SAID does not confer adverse prognosis in retrospective studies. Polyserositis is less common; this may result from leukemic infiltrate or result from autoimmunity. Treatment of serositis includes steroids and cytoreductive agents. Serositis may confer poor prognosis and hypomethylating therapy may improve the outcome.

Tick-borne illness has been increasingly on the rise, since the first human case was reported in the late 1980s. Ehrlichia chaffeensis is one of the most common reported causes of tick-borne illness, particularly in the southern states of the United States. The clinical picture presents as a paradigm to the clinician, often missing the diagnosis without an appropriate history being taken and sometimes mistreated for other conditions. With the number of cases on the rise, new manifestations and clinical presentations due to E chaffeensis continue to be reported. Our case report is one such case in a 46-year-old male from Arkansas, with known exposure to multiple tick bites who presented with classical symptoms and laboratory values of tick-borne illness leading to atrial flutter. This unusual manifestation of atrial flutter due to tick-borne illness is rare and poorly understood. Further studies on tick-borne illness due to E chaffeensis may be needed to understand the systemic causes of the bacteria. In addition, in our case report, we bring to attention the standard presentation (symptoms, signs, and laboratory values) of tick-borne illness due to E chaffeensis along with the current standard for diagnosis and treatment.

Background In the US, pneumonia is the most common cause of a hospital admission. Prior analysis has shown that nearly one in six patients will have an all-cause 30-day readmission. Given the disparities in access to healthcare between rural and urban settings, we sought to see if patient location influenced the incidence rate for 30-day readmission after treatment for Gram Positive Pneumonia. Methods We utilized Agency of Healthcare Research and Quality’s (AHRQ) 2014 Nationwide Readmission Database to identify index admissions with a principal diagnosis of Gram Positive Pneumonia (ICD-9 codes 482.3, 482.31, 482.32, and 482.39 for streptococcus and 482.40, 482.41, 482.42, and 482.49 for staphylococcus). The 2013 NCHS Urban-Rural Classification System was used to classify if originating from an urban or rural location. Applicable admissions were all adults (age &gt;= 18) from January 1 to November 30, 2014. Patients who died during index admission and those with missing covariates were excluded. All-cause readmissions within 30-days of an index admission were analyzed. Predictors for readmission were determined using a multivariable logistic regression model. Results A total of 8,130 patients met criteria for inclusion of which 1,631 (20.06%) were readmitted (all-cause) within 30-days. There was no statistically significant difference in readmission between patients from a rural (18.7%) or urban (20.4%) location. The statistically significant predictors for readmission for patients from a rural location were those admitted on a weekend (OR: 1.41, CI: 1.04-1.90), discharged to short term hospital (OR: 2.70, CI: 1.18-6.19) or AMA (OR: 6.53, CI: 1.46-29.10), and those with a LOS between 7 and 14 days (OR: 1.48, CI: 1.10-2.00). For patients from an urban location, statistically significant predictors were those admitted on a weekend (OR: 1.17, CI 1.02-1.34), discharged AMA (OR: 2.89, CI: 1.74-4.78), LOS between 7 and 14 days (OR: 1.19, CI: 1.03-1.37) and those with CKD (OR: 1.20, CI: 1.03-1.39). Conclusion The risk factors for readmission after Gram Positive Pneumonia for patients from a rural and urban location are similar. More research is needed to develop interventions for those who are at risk for readmission after Pneumonia to reduce future morbidity and mortality. Disclosures All Authors: No reported disclosures

An 80-year-old male patient presented with sepsis secondary to infected central line which was placed for native aortic valve endocarditis. He also had melena and abdominal pain prior to his presentation. Abdominal computed tomography (CT) was done, which showed cholelithiasis. Esophagogastroduodenoscopy was also done with no source of bleeding identified. Later, he developed hemodynamic instability requiring aggressive fluid resuscitation and multiple packed blood cell transfusions. In view of his hemodynamic instability, a repeat abdominal CT scan showed air droplets within the gallbladder pneumobilia, ascites, diverticulosis, and a bleeding infrahepatic hematoma measuring 6 × 10 cm, which was not on his prior scan 2 days prior. A mesenteric arteriogram was performed that identified an aneurysm of the right hepatic artery with no active bleeding; therefore, it was coiled. Due to his continued clinical decompensation, he underwent an urgent open cholecystectomy, in which serosanguineous fluid, cholecystocolic fistula, and old clot related to his previous bleed were encountered. However, control of bleeding was difficult, and the patient expired. We report this case of right hepatic artery aneurysm that we believe its etiology was related to eroding cholecystitis.